Uterine botulinum toxin injections in severe dysmenorrhea, dyspareunia and chronic pelvic pain: Results on quality of life, pain level and medical consumption

OBJECTIVE

To evaluate quality of life (Qol), pain level and medical consumption before and after uterine botulinum toxin (BT) injections in severe dysmenorrhea, dyspareunia and chronic pelvic pain.

METHODS

This was a before and after study using the database of a pilot study (Open-label non comparative study, on 30 patients, with severe dysmenorrhoea in therapeutic failure) assessing efficacy and cost of uterine injection of BT in women with chronic pelvic pain after failure of conventional treatment (hormonal and analgesics) (CT). Main clinical outcome: Patient Global Impression of Improvement (PGI-I), EuroQol health-related QoL (EQ-5D-5L), EuroQol-visual analogue scale (EQ-VAS), Female Sexual Function Index (FSFI), utility measure of health-related quality of life (also called health state preference values), cost and of health care consumption were collected prospectively and analysed in the two phases (before and after). The two timepoints were 12 months before uterine BT injection, when the patient had been receiving CT, and 12 months after uterine BT injection.

RESULTS

Median visual analogue scale scores were significantly improved by BT regarding the patients' main source of pain (31.6 vs 80.55; p < 0.00001). We also noted a significant reduction in the proportion of patients who reported dyspareunia [15 (75%) vs 3 (15%) patients, p = 0.001] and pain during menstruation (p < 0.0001). The PGI-I scale showed a significant increase in the proportion of patients who were satisfied with their treatment after receiving the BT injection. The injection of BT was frequently associated with increase in QoL and a reduction in health care consumption, and cost: 714.82 €+/- €336.43 (BT) versus 1104.16 €+/- €227.37 (CT), which could result in substantial savings approximately (389,34€) per patient.

CONCLUSION

This study revealed the clinical effectiveness of BT injections on dysmenorrhea, chronic pelvic pain as well as reduction of cost and health care consumption, in our population, which is innovative since no standard of treatment exists in this domain.

Cost effectiveness of pegfilgrastim versus filgrastim after high-dose chemotherapy and autologous stem cell transplantation in patients with lymphoma and myeloma: an economic evaluation of the PALM Trial

BACKGROUND

Use of the recombinant human granulocyte colony-stimulating factor (rhG-CSF) filgrastim accelerates neutrophil recovery following myelosuppressive chemotherapy. Since filgrastim requires multiple daily administrations, forms of rhG-CSF with a longer half life, including pegfilgrastim, have been developed. Pegfilgrastim is safe and effective in supporting neutrophil recovery and reducing febrile neutropenia after conventional chemotherapy. Pegfilgrastim has also been successfully used to support patients undergoing peripheral blood stem cell (PBSC) transplantation for haematological malignancies. To our knowledge, no cost-effectiveness analysis (CEA) of pegfilgrastim in this setting has been published yet.

OBJECTIVE

We undertook a CEA to compare a single injection of pegfilgrastim versus repeated administrations of filgrastim in patients who had undergone PBSC transplantation for lymphoma or myeloma. The CEA was set in France and covered a period of 100 ± 10 days from transplant.

METHODS

The CEA was designed as part of an open-label, multicentre, randomized phase II trial. Costs were assessed from the hospital's point of view and are expressed in 2009 euros. Costs computation focused on inpatient, outpatient, and home care. Costs in the two arms of the study were compared using the Mann-Whitney test. When differences were statistically significant, multiple regression analyses were performed in order to identify cost drivers. Incremental cost-effectiveness ratios (ICER) were calculated for the major endpoints of the trial; i.e., duration of febrile neutropenia (absolute neutrophil count [ANC] <0.5 × 10(9)/L and temperature ≥38 °C), duration of neutropenia (ANC <1.0 × 10(9)/L and ANC <0.5 × 10(9)/L), duration of thrombopenia (platelets <50 × 10(9)/L and <20 × 10(9)/L), and days with a temperature ≥38 °C). Uncertainty around the ICER was captured by a probabilistic analysis using a non-parametric bootstrap method.

RESULTS

151 patients were enrolled at ten French centres from October 2008 to September 2009. The mean total cost in the pegfilgrastim arm of the study (n = 74) was <euro>25,024 (SD 9,945). That in the filgrastim arm (n = 76) was <euro>28,700 (SD 20,597). Pegfilgrastim strictly dominated filgrastim for days of febrile neutropenia avoided, days of neutropenia (ANC <1.0 × 10(9)/L) avoided, days of thrombopenia (platelets <20 × 10(9)/L) avoided, and days with temperature ≥38 °C) avoided. Pegfilgrastim was less costly and less effective than filgrastim for the number of days with ANC <0.5 × 10(9)/L avoided and the number of days with platelets <50.0 × 10(9)/L avoided. Taking uncertainty into account, the probabilities that pegfilgrastim strictly dominated filgrastim were 67 % for febrile neutropenia, 86 % for neutropenia (ANC <1.0 × 10(9)/L), 59 % for thrombopenia (platelets <20 × 10(9)/L), 86 % for temperature ≥38 °C, 32 % for neutropenia (ANC <0.5 × 10(9)/L), and 43 % for thrombopenia (platelets <50 × 10(9)/L). Conversely, the probability that filgrastim strictly dominated pegfilgrastim for neutropenia (ANC <0.5 × 10(9)/L) is 5 %.

CONCLUSION

This study found no evidence that the use of pegfilgrastim is associated with greater cost in lymphoma and myeloma patients after high-dose chemotherapy and PBSC transplantation.

Clinicians' adherence versus non adherence to practice guidelines in the management of patients with sarcoma: a cost-effectiveness assessment in two European regions

BACKGROUND

Although the management of sarcoma is improving, non adherence to clinical practice guidelines (CPGs) remains high, mainly because of the low incidence of the disease and the variety of histological subtypes. Since little is known about the health economics of sarcoma, we undertook a cost-effectiveness analysis (within the CONnective TIssue CAncer NETwork, CONTICANET) comparing costs and outcomes when clinicians adhered to CPGs and when they did not.

METHODS

Patients studied had a histological diagnosis of sarcoma, were older than 15 years, and had been treated in the Rhône-Alpes region of France (in 2005/2006) or in the Veneto region of Italy (in 2007). Data collected retrospectively for the three years after diagnosis were used to determine relapse free survival and health costs (adopting the hospital's perspective and a microcosting approach). All costs were expressed in euros (€) at their 2009 value. A 4% annual discount rate was applied to both costs and effects. The incremental cost-effectiveness ratio (ICER) was expressed as cost per relapse-free year gained when management was compliant with CPGs compared with when it was not. To capture uncertainty surrounding ICER, a probabilistic sensitivity analysis was performed based on a non-parametric bootstrap method.

RESULTS

A total of 219 patients were included in the study. Compliance with CPGs was observed for 118 patients (54%). Average total costs reached 23,571 euros when treatment was in accordance with CPGs and 27,313 euros when it was not. In relation to relapse-free survival, compliance with CPGs strictly dominates non compliance, i.e. it is both less costly and more effective. Taking uncertainty into account, the probability that compliance with CPGs still strictly dominates was 75%.

CONCLUSIONS

Our findings should encourage physicians to increase their compliance with CPGs and healthcare administrators to invest in the implementation of CPGs in the management of sarcoma.

Physical activity and risk of metabolic syndrome in an urban Mexican cohort

Background

In the Mexican population metabolic syndrome (MS) is highly prevalent. It is well documented that regular physical activity (PA) prevents coronary diseases, type 2 diabetes and MS. Most studies of PA have focused on moderate-vigorous leisure-time activity, because it involves higher energy expenditures, increase physical fitness, and decrease the risk of MS. However, for most people it is difficult to get a significant amount of PA from only moderately-vigorous leisure activity, so workplace activity may be an option for working populations, because, although may not be as vigorous in terms of cardio-respiratory efforts, it comprises a considerable proportion of the total daily activity with important energy expenditure. Since studies have also documented that different types and intensity of daily PA, including low-intensity, seem to confer important health benefits such as prevent MS, we sought to assess the impact of different amounts of leisure-time and workplace activities, including low-intensity level on MS prevention, in a sample of urban Mexican adults.

Methods

The study population consisted of 5118 employees and their relatives, aged 20 to 70 years, who were enrolled in the baseline evaluation of a cohort study. MS was assessed according to the criteria of the National Cholesterol Education Program, ATP III and physical activity with a validated self-administered questionnaire. Associations between physical activity and MS risk were assessed with multivariate logistic regression models.

Results

The prevalence of the components of MS in the study population were: high glucose levels 14.2%, high triglycerides 40.9%, high blood pressure 20.4%, greater than healthful waist circumference 43.2% and low-high density lipoprotein 76.9%. The prevalence of MS was 24.4%; 25.3% in men and 21.8% in women. MS risk was reduced among men (OR 0.72; 95%CI 0.57–0.95) and women (OR 0.78; 95%CI 0.64–0.94) who reported an amount of ≥30 minutes/day of leisure-time activity, and among women who reported an amount of ≥3 hours/day of workplace activity (OR 0.75; 95%CI 0.59–0.96).

Conclusion

Our results indicate that both leisure-time and workplace activity at different intensity levels, including low-intensity significantly reduce the risk of MS. This finding highlights the need for more recommendations regarding the specific amount and intensity of leisure-time and workplace activity needed to prevent MS.

Preoperative weekly cisplatin-epirubicin-paclitaxel with G-CSF support in triple-negative large operable breast cancer

BACKGROUND

Findings from our previously published phase II study showed a high pathologic complete remission (pCR) rate in patients with triple-negative large operable breast cancer after the administration of eight cisplatin-epirubicin-paclitaxel (PET) weekly cycles. The safety and efficacy data of the initial population were updated, with inclusion of additional experience with the same therapy.

METHODS

Patients with triple-negative large operable breast cancer (T2-T3 N0-1; T > 3 cm) received eight preoperative weekly cycles of cisplatin 30 mg/m2, epirubicin 50 mg/m2, paclitaxel (Taxol) 120 mg/m2, with granulocyte colony-stimulating factor (5 microg/kg days 3-5) support.

RESULTS

Overall 74 consecutive patients (T2/T3 = 35/39; N0/N+ = 26/48) were treated, from May 1999 to May 2008. At pathological assessment, 46 women (62%; 95% confidence interval 50-73) showed pCR in both breast and axilla. At a 41-month median follow-up (range 3-119), 13 events (nine distant metastases) had occurred, 5-year projected disease-free survival (DFS) and distant disease-free survival being 76% and 84%, respectively. Five-year DFS was 90% and 56% in pCRs and non-pCRs, respectively. Severe neutropenia and anemia occurred in 23 (31%) and eight (10.8%) patients, respectively. Severe non-hematological toxicity was recorded in <20% of patients. Peripheral neuropathy was quite frequent but never severe.

CONCLUSIONS

Eight weekly PET cycles are a highly effective primary treatment in women with triple-negative large operable breast cancer. This approach results in a very promising long-term DFS in this poor prognosis population. This triplet regimen is worthy of evaluation in phase III trials.

Impact of uncertainty on cost-effectiveness analysis of medical strategies: The case of high-dose chemotherapy for breast cancer patients

Objectives: The object of this study was to determine, taking into account uncertainty on cost and outcome parameters, the cost-effectiveness of high-dose chemotherapy (HDC) compared with conventional chemotherapy for advanced breast cancer patients.

Methods: An analysis was conducted for 300 patients included in a randomized clinical trial designed to evaluate the benefits, in terms of disease-free survival and overall survival, of adding a single course of HDC to a four-cycle conventional-dose chemotherapy for breast cancer patients with axillary lymph node invasion. Costs were estimated from a detailed observation of physical quantities consumed, and the Kaplan–Meier method was used to evaluate mean survival times. Incremental cost-effectiveness ratios were evaluated successively considering disease-free survival and overall survival outcomes. Handling of uncertainty consisted in construction of confidence intervals for these ratios, using the truncated Fieller method.

Results: The cost per disease-free life year gained was evaluated at 13,074€, a value that seems to be acceptable to society. However, handling uncertainty shows that the upper bound of the confidence interval is around 38,000€, which is nearly three times higher. Moreover, as no difference was demonstrated in overall survival between treatments, cost-effectiveness analysis, that is a cost minimization, indicated that the intensive treatment is a dominated strategy involving an extra cost of 7,400€, for no added benefit.

Conclusions: Adding a single course of HDC led to a clinical benefit in terms of disease-free survival for an additional cost that seems to be acceptable, considering the point estimate of the ratio. However, handling uncertainty indicates a maximum ratio for which conclusions have to be discussed.

[Surgical treatment in day surgery of uncertain breast lesions]

AIM

New models of care are proposed to reduce the costs of traditional hospitalization and to improve the utilization of resources in surgery. Day surgery is widely employed in breast surgery. In this study we report the conversion rate and causes in ordinary hospitalization and we identify some contraindications related to breast surgery in day surgery.

METHODS

A cohort study was performed on 306 patients operated on between July 1999 and December 2001 for breast lesions with uncertain interpretation at the clinical and/or instrumental examination. Those patients who lived at a distance of less than 50 km from the hospital, had a telephone, a suitable house, direct family support and, if necessary, could benefit from home health care in addition to hospitalization, were considered as eligible to day surgery. The kind of anesthesia and hospital admission were established after clinical, psycho-emotional, and socio-familiar evaluation of the patients by the surgeon and the anesthetist.

RESULTS

A total of 250 excisional biopsies and 56 biopsies with a Mammotome were performed. Surgery was performed under local anesthesia in 278 patients and general anesthesia in 28 subjects. Observation exceeding 24 hours was only necessary in 10 patients reporting hypotension syndrome and anxiety. The conversion rate in ordinary hospitalization was 0.3%. Postoperative morbidity was 1%.

CONCLUSION

Day surgery is an effective model of care in breast surgery for diagnostic and therapeutic purposes without axillary dissection. A good selection of patients, perfect interdisciplinary collaboration, and an efficient structural organization are necessary to control the complication and conversion rates of traditional hospitalization.

Modifications of cerebral vascular resistance and autoregulation after graft reperfusion during human orthotopic liver transplantation

We have studied cerebral blood flow velocity (CBFV) and cerebral autoregulation (CA) in 23 orthotopic liver transplantation (OLT) patients using transcranial doppler. CBFV was continuously recorded using a fixed (helmet) 2-Mz probe through the trans-temporal window. CA changes were studied using a linear regression analysis of percentile changes in CBFV and mean arterial blood pressure (MABP) after phenylephrine infusion compared with baseline. Pearson's "r" coefficient was considered an index of CA. In case of autoregulation is lost "r" tends to 1, thus representing complete dependence of CBFV on MABP. We regarded the slope coefficient parameter "S" as an index of cerebral vascular resistance (CVR), namely, the ratio of the corresponding variations of CBFV to MABP. Wilcoxon test showed a significant increase in both "r" and "S" between the anhepatic versus postreperfusion phases (within the first hour) and versus recovery in the neohepatic phase (end of surgery). A decreased CVR was observed within the first hour after graft reperfusion producing a loss of CA. These phenomena lead to an increase of CBFV and exposed the brain to hyperperfusion.

Portal vein pressure and graft oxygen consumption monitoring during liver transplantation

Abnormal splanchnic circulation (ASC) is often detected too late, when hepatic circulation is already irreversibly compromised. If we could detect surgical or metabolic problems early after graft reperfusion, we might be able to correct them immediately before the damage becomes irreversible. The aim of this study was to determine if ASC can be predicted early after liver transplantation (LT) using portal vein pressure measurements and graft oxygen consumption monitoring.

PATIENTS AND METHODS

Twenty-patients (13 men, 7 women of mean age 46 years) undergoing LT with the piggyback technique for hepatitis C virus (HCV)/hepatitis B virus (HBV)-related cirrhosis were retrospectively divided in two groups. Group A (16 patients), in which LT was successful, and group B (4 patients) in which LT was unsuccessful because of primary nonfunction (2 patients), infrahepatic portal vein thrombosis (1 patient), or hepatic vein kinking (1 patient). We then compared the portal blood pressure values and the prehepatic and posthepatic oxygen content difference (p-pDO(2)) before portal clamping; at the end of anhepatic phase; 5, 15, and 25 minutes after portal vein (PV) reperfusion; and 5, 20, 40, and 100 minutes after hepatic artery anastomosis.

RESULTS

Early after graft reperfusion; portal pressure decreased to levels lower than that at baseline in group A, but remained high until the end of surgery in group B. At the end of surgery, p-pDO(2) increased more among group B than group A.

CONCLUSION

ASC, specifically an increased PV resistance, can be predicted early after LT by portal vein pressure measurements and graft oxygen consumption monitoring.

[The handling of uncertainty in economic evaluations of health care strategies]

BACKGROUND

The recent development of prospective economic evaluations in association with randomized controlled clinical trials has provided clinical and economic data allowing a statistical analysis of uncertainty. Pertinent comparison of alternative medical strategies in the cost-effectiveness analysis requires analysis of the incremental cost-effectiveness ratio. In this work, we were interested in developing confidence regions of the cost-effectiveness ratio in order to take into consideration its uncertainty which creates a certain number of problems when the denominator approaches zero. Our objectives were to conduct a critical analysis of the different estimations used and examine their application in the decision making process.

METHODS

There are two kinds of methods: those based on the density of the estimated ratio (Taylor method, parametric and non-parametric bootstrap methods such as percentile, percentile-t and bias-corrected and accelerated methods) and those based on the bivariate density of the variable pair: difference of average costs, difference of average effects (box method, ellipse method, and Fieller method).

RESULTS

We showed that methods based on the density of the ratio become unstable and inapplicable when the statistical difference of average effects tends towards zero. In practice however, data often take on such a pattern. We give an example of an economic evaluation as an illustration. Bivariate density methods do not have this drawback. Moreover, the "mirror decision" phenomenon requires that the region of confidence be a directed single confidence sector for valid decision making.

CONCLUSIONS

Uncertainty must be taken into account for all economic evaluations but the use of undirected confidence regions is inappropriate as a decision-making tool.

[Subarachnoid hemorrhage and pregnancy]

Intracranial haemorrhage from ruptured aneurysm or bleeding in arteriovenous malformation is rare, but may result in significant maternal and fetal mortality and serious neurological morbidity in survivors. Surgical intervention creates risks for the mother and her fetus, but is the best form of management. The anaesthetic procedure can present many clinical dilemmas, one of which is the role of induced hypotension. This review will focus on the diagnosis and management of this dramatic event.

[The recurrence of hepatitic C in orthotopic liver transplantation]

BACKGROUND

This study is a review of hepatitis C recurrence in patients undergoing an orthotopic liver transplantation (OLT); to verify how many patients HCV-positive before OLT confirm a persistent viremia after OLT and how many with viremia show hepatitis histological evidence.

METHODS

Thirty consecutive patients, 24 males, median age 52.5 underwent OLT for posthepatitic C cirrhosis since January 1993 in the "Transplantation Center" of Genoa. Serology included anti-HCV search, HCV-RNA and HBV-DNA determinations, biopses were performed in the transplanted liver within the month after operation, subsequently at every hepatic enzymes increase.

RESULTS

Twenty-one patients are currently alive, median follow-up of 14.5 months. Before OLT anti-HCV antibodies search was positive in all the patients while the HCV-RNA by PCR resulted positive in 17 and negative in 4. Before OLT the HBV-DNA in patients with associated hepatitis B was negative. After OLT 5 patients, of the 17 HCV-RNA positive before OLT, have turned negative then all became again positive from 6 to 12 months later; 2 of the 4 patients HCV-RNA negative before OLT have turned positive, and remained still negative two with hepatitis C associated with hepatitis B. Although viral replication was present in 95% of the patients, clinical and histological evidence of recurrence was ascertained only in 29%.

CONCLUSIONS

It should be noted that the hepatitis histological picture doesn't correspond to a severe worsening of clinical conditions, an evolution justifying transplantation. The long-term results of this therapeutic choice are still uncertain due to the high incidence of recurrences.

[Severe infections after orthotopic hepatic transplant]

METHODS

The authors analysed severe infections in 43 consecutive patients undergoing orthotopic liver transplant. Prophylaxis and full anti-infection monitoring was performed in all cases. Immunosuppressive therapy was administered in the form of primary cyclosporine in 27 cases and primary OKT3 in 16 cases.

RESULTS

Twenty-seven patients are still alive (median 8 months, range 2-40) and 16 died (median 22 days, range 10-92) of whom 4 without and 12 with infection, including two deaths owing to non-correlated causes with infection after recovery. Twenty-three patients underwent 33 episodes of severe infection (plus four with inconclusive positive cultures) without any case of protozoal or viral infection. All episodes occurred within two months of surgery and affected the lung (10), abdomen (7), lung + abdomen (1), urinary tract (1), lung + urinary tract (1), as well as two diffused cases and 7 cases of isolated bacteremia deriving from the donor (1), venous catheters (3), mild otorhinolaryngeal infection (1) and two unknown sources (2). Eighteen infective agents were identified in 45 cases. The bacteria involved in single-agent episodes were: 11 Gram+, 9 Gram- and five fungi. Polymicrobic and bacterial/fungal episodes were repeatedly observed in two and two cases. Postoperative renal insufficiency significantly influenced both the incidence of and mortality due to infection. Overall mortality was also influenced by early graft function, postoperative complications and reoperations, and the incidence of infections by the portal clamping stage, reject and prolonged coma.

CONCLUSIONS

The absence of severe viral infections and the gradual reduction of mortality caused by infection appear to be parallel to the aggressive antiviral prophylaxis, the gradual improvement of intra- and postoperative management and primary immunosuppression with OKT3.

Metoclopramide increases plasma but not cerebrospinal fluid vasopressin levels in man: study in hydrocephalic patients

Arginine vasopressin (AVP) concentrations were determined in plasma and in cerebrospinal fluid (CSF) in 8 adult male patients suffering from hydrocephalus of various etiologies, before and after intravenous administration of 10 mg metoclopramide. Metoclopramide was able to increase the plasma (2.6 +/- 0.2 ng/l in basal conditions and 6.1 +/- 0.6 ng/l at 30 min) but not the CSF AVP levels. The results suggest that the neurons which secrete AVP into the CSF may be functionally different from those secreting into the peripheral circulation.

[Evaluation of 2 modalities of use of propofol in cerebral angiography]

Fifty eight adult patients suffering from different intracranial lesions and scheduled for cerebral angiography were given propofol. In the first group (38 patients) brief periods of anaesthesia were induced and reinduced by means of 1.5 mg/kg of propofol iv and sometimes extended with boluses of 25-50 mg of this anesthetic. The patients were premedicated with 0.5 mg atropine im 30-40 min before the induction. Fentanyl, droperidol and diazepam in various combinations and doses were injected, im together with the atropine and iv 1-2 min before the induction, to obtain long-lasting sedations. In the second group (20 patients) the induction of the anaesthesia started 20-35 min after 0.5 mg of atropine im and 1 min after 0.1 mg of fentanyl iv. The induction was based on a bolus of 2.5 mg/kg of propofol and it was followed by suxamethonium, tracheal intubation and mechanical ventilation with N2O 70% in O2. An adequate depth of anaesthesia was maintained with supplemental doses of 50 mg of propofol, frequently associated with 25 mg of suxamethonium. Both methods proved to be reliable and safe. Nevertheless, the second method provided a better stability as far as a number of physiologic variables is concerned.

Diurnal changes of plasma and cerebrospinal fluid somatostatin and 24-h growth hormone secretory pattern in man. A study in hydrocephalic patients

Somatostatin concentration was determined in plasma and in cerebrospinal fluid during a 24-h period in 7 male patients suffering from hydrocephalus of differing aetiologies. Blood and ventricular cerebrospinal fluid samples were taken every 2 h during the day (08.00-22.00 h) and every hour during the night (24.00-07.00 h). Simultaneously, plasma growth hormone levels were also evaluated. Plasma SRIH levels showed significant circadian variations with highest values in the daytime and lowest values during the night. Cerebrospinal fluid SRIH did not show any significant time-related circadian changes. Plasma GH levels showed the well-known circadian pattern in the majority of patients. No significant correlation was found between the plasma GH and plasma or cerebrospinal fluid SRIH values recorded during the 24-h period. Results suggest that peripheral SRIH does not play any major role in the control of the 24-h GH secretory pattern in man.

Diurnal pattern of plasma and cerebrospinal-fluid vasopressin levels in hydrocephalic patients: absence of a circadian rhythm and of a correlation between plasma and cerebrospinal-fluid variations

The arginine vasopressin (AVP) concentrations were determined in plasma and in cerebrospinal fluid (CSF) during a 24-hour period in 7 male patients suffering from hydrocephalus of differing etiologies. Blood and ventricular CSF samples were simultaneously collected every 2 h during the day (08.00-22.00) and every hour during the night (24.00-07.00). In both plasma and CSF, the AVP levels did not show significant time-related circadian variations. No significant correlation was found between the plasma and CSF AVP values during the 24-hour period. The data obtained indicate the absence of the plasma and CSF AVP circadian rhythm in hydrocephalic patients and suggest that in these patients, and possibly in healthy humans, physiological stimuli which are able to induce variations in the plasma AVP concentration during daily life do not alter the CSF AVP content.

Diurnal beta-endorphin changes in human cerebrospinal fluid

Plasma and cerebrospinal fluid (CSF) beta-endorphin levels were determined by a RIA method in seven hydrocephalic male patients. The samples were simultaneously collected every two hours from 8 AM to 12 midnight and every hour from 1 AM to 7 AM. In both plasma and CSF beta-endorphin levels showed significant time-related variations during the 24 hour period. These results suggest the existence of diurnal CSF beta-endorphin variations analogous to those observed in plasma.

Variations of prolactin content in human cerebrospinal fluid after metoclopramide and morphine

Serum and cerebrospinal fluid (CSF) prolactin (PRL) concentrations were determined in fourteen patients of both sexes suffering from hydrocephalus, in basal conditions and after i.m. administration of 10 mg metoclopramide or 10 mg morphine. A significant increase in both serum and CSF hormone values was found after administration of both drugs. Serum and CSF PRL values after metoclopramide administration increased earlier and to a greater extent than after morphine. Furthermore, the metoclopramide induced CSF PRL increase immediately followed the serum peak, whereas after morphine administration an evident delay in the CSF hormone peak with respect to the serum increase was found. These data suggest that PRL entry in the CSF compartment is subject to a controlling mechanism which acts at the blood/brain barrier.

Diurnal prolactin changes in human cerebrospinal fluid

Eight adult male patients suffering from hydrocephalus of differing aetiologies were investigated in order to detect the existence of diurnal variations of prolactin (PRL) concentration in human cerebrospinal fluid (CSF). Blood and ventricular CSF samples were taken every 2 h during the day (0800-2200 h) and every hour during the night (2300-0700 h). CSF mean PRL levels showed significant nyctohemeral variations with low levels (2.1 +/- 0.3 ng/ml) during day-time and higher levels at night (3.3 +/- 0.1 ng/ml), similar to that observed in serum (PRL values: 16.4 +/- 5.2 and 24.8 +/- 4.3 ng/ml during day and night periods respectively). The presence of a 24 h CSF PRL secretory profile similar to that in serum was shown in six patients with normal 24 h mean PRL values and normal diurnal changes in serum. In two patients with an altered serum 24 h secretory pattern no significant nyctohemeral variations in CSF PRL levels were found. Present data show the existence in man of nyctohemeral variations in CSF PRL content related to the 24 h changes of PRL levels in serum.

Changes of CSF prolactin induced by metoclopramide in man

A sharp increase in serum and CSF prolactin (PRL) values after acute metoclopramide (10 mg i.m.) administration was found in six male patients without endocrine diseases. Peak values occurred simultaneously in serum and in CSF. This finding suggests the possibility that CSF PRL content depends also on the retrograde transport from pituitary gland.

Electromanometric confirmation of needle position in haemopericardium with severe tamponade

Simultaneous recording of the electrocardiogram and of the pressure transmitted through the drainage needle in patients with haemopericardium provided confirmation that the needle tip was in the pericardial cavity. Proper position was indicated by a positive pressure wave beginning before the QRS complex, reaching its maximum value in the first part of the ST segment and ending with the T wave. In contrast, ventricular penetration was signalled by a positive pressure wave beginning in the first part of the QRS complex, reaching its maximum during the T wave and ending between the T and P waves.

[Analysis of EEG frequency in althesin anesthesia]

Twelve subjects were given Althesin until the EEG level of burst suppression was reached. The cerebral electrical activity was continuously monitored by the conventional EEG-tracing method and by a tracing compression technique (BFA), based on the time to-frequency domain conversion and the display of the spectra in prospectical array. The BFA computed in real time the power spectra of 64 frequencies (0,25-16 Hz) by means of the Fourier's transform. The depth of Althesin anesthesia proved to correlate with the EEG spectra.

[Effects of the intravenous infusion of althesin on intracranial pressure and related functions]

30-60 min after the i.m. administration of 0.5 mg atropine sulphate, 9 adult conscious neurosurgical patients on spontaneous ventilation were given a total of 12 i.v. infusions of Althesin at a rate of 0,25-0,60 ml/kg/h able to induce stable clinical and EEG levels of anaesthesia. PICm, PAm and PVCm respectively decreased in all, in ten and in six administrations. The PAm decreased below 60 mmHg in only one case, in another there was no change and in another still it increased in a stable manner. In all cases PICm, PAm and PVCm decreased by a mean of 3.88 +/- 1.22 (P < 0,05), 20,76 +/- 17,44 (P < 0,05) and 0,90 +/- 1,50 mmHg. The paCO2 generally increased and, in only one case, did it induce an intracranial hypertensive reaction; the paO2 was frequently reduced. The interruption in the infusion was followed by the regression of all effects. This appened for the PICm and PAm without dangerous rebound effects. The clinical use of Althesin in neurosurgical patients is discussed with regards to problems of anaesthesia and intensive care.

[Effects of an intravenous bolus of althesin on intracranial pressure and related functions]

30-40 min after i.m. administration of 0.5 mg atropine sulphate, 8 adult conscious neurosurgical patients on spontaneous ventilation were given a total of 10 rapid i.v. injections of Althesin at a dosage of 40-50 (45.5 +/- 4.33 as a mean) microliter/kg. Method was able to induce clinical and EEG signs of deep anaesthesia. PICm and PAm decreased in all cases by 6.82 +/- 3.91 (P < 0,05) and 20.18 +/- 9.30 mmHg respectively; PVCm decreased in only half of the cases. The intracranial hypotensive effect was positively correlated to the basal PICm (P < 0.05) and resulted proportionately more marked in cases with greater signs of EEG depression. The PAm never decreased below 60 mmHg. The paCO2 was generally increased and the paO2 was always decreased. The intracranial hypotensive effects regressed 12-23 min after the injection without dangerous rebound effects; recovery of the PAm was slower. The use of Althesin in the anaesthesia and in the intensive care of neurosurgical patients is discussed.

Propranolol in neurosurgical patients with sinus tachycardia. Cardiovascular effects and mode of use

Cardiac rate (CR) and systolic arterial blood pressure (ABP) response to the intravenous injection of one, two, or three mg propranolol were recorded in 77 patients with traumatic, neoplastic, or haemorrhagic intracranial lesions and sinus tachycardia. In most patients tachycardia occurred with no cause except the intracranial lesion; in the other patients induction of general anaesthesia or surgical procedures on the brain appeared to have an initiating role. A central imbalance, with increased sympathetic cardiotropic influences is suggested and discussed. (I) First administrations of propranolol always reduced CR but had different effects on ABP from case to case; in all the patients 2.05 +/- 0.84 mg of drug lowered CR by 28 +/- 14/min (P less than 0.01), and ABP by 4.7 +/- 11 torr. CR decrease and ABP changes were without relation to the injected dose. Previous digitalization (desacetyllanatoside C) did not modify CR response to propranolol but reduced (P less than 0.05) its arterial hypotensive action. Positive correlations were found between basal CR and CR decrease (P less than 0.01), basal CR and ABP changes (P less than 0.01), CR decrease and ABP changes (P less than 0.05). Halothane appeared to potentiate CR response (P less than 0.01). (II) CR effect was less when the same dose of propranolol was repeated within 90 min (P less than or equal to 0.05). Usefulness and the mode of use of propranolol were critically evaluated.